Diabetic Foot Requires Special Care

History and Presenting Symptoms

A 66 year-old female presents with aching lower back pain and numbness extending into both feet. She reports having had occasional lower back pain for many years, but has only noticed the foot numbness in the past six months. This is getting more constant, which concerns her. She recalls no specific back or foot injuries. On a 100mm Visual Analog Scale, she rates her low back pain as usually 20-30mm. Both feet are equally numb, with no noticeable pattern or causative activity.

Exam Findings

Vitals. This 5’4’’ aging female weighs 168 lbs, which results in a BMI of 29. She is aware that she is bordering on obesity and has been unsuccessfully trying to lose weight. She hasn’t been able to exercise recently because of her back pain and numb feet. Her blood pressure is http://www.theamericanchiropractor.com/images/danchickissue6.jpgelevated at 144/96 mmHg and her pulse rate is 84 bpm.

Posture and gait. Standing postural evaluation finds evidence of abdominal obesity, with a loss of the lumbar curve, and an accentuated thoracic kyphosis. There is no significant lateral listing of her pelvis or spine. She demonstrates bilateral calcaneal eversion, with no evidence of medial arches bilaterally. During gait, both feet pronate substantially and flare outwards (toe-out).

Chiropractic evaluation. Motion palpation identifies numerous limitations in intersegmental spinal motion: the left SI joint, the lumbosacral junction on the left, L3/L4 on the right, T11/12 generally and at the cervicothoracic junction. Palpation finds generalized paraspinal muscle tenderness, but no specific muscle spasm in these regions. All active thoracolumbar spinal ranges of motion are limited slightly by aching pain and stiffness. Provocative orthopedic and neurological tests for nerve root impingement and/or radiculopathy are negative.

Lower extremities. Both feet are generally insensitive to both pinprick and dull pressure evaluation. No specific dermatomal or peripheral nerve pattern is identified. Manual testing finds no significant muscle weakness in the fibular (peroneal) or anterior tibial muscles on either side. The feet and ankles are moderately edematous and the skin is somewhat blotchy.

Imaging and Lab

A weightbearing lumbopelvic X-ray series finds generalized loss of lumbar disc heights, most obvious at the lumbosacral joint and L3/L4. The L3 vertebral body is translated forward approximately 5 mm. The sacral base angle and lumbar lordosis are both decreased, consistent with her postural analysis. Fasting glucose level is found to be 134 mg/dL.

Clinical Impression

“Diabesity” (central obesity and type 2 diabetes) with early peripheral neuropathy. This is accompanied by degenerative lumbar spondylolisthesis. She also provides evidence of poor support from the lower extremities, with hyperpronation and substantial calcaneal eversion bilaterally.

Treatment Plan

Adjustments. Specific, corrective adjustments for the SI joints and the lumbar and cervicothoracic regions were provided as needed, with good response. Manipulation of the feet and knees was also performed.

Support. Custom-made, flexible orthotics were provided, made of comfortable and supple viscoelastic materials. She was given instructions in proper shoe selection, including the importance of correct sizing. It turned out that her shoes were too small and she purchased better-fitting shoes (one full size larger), which then accommodated the inserts without difficulty.

Rehabilitation. She received instruction in a comprehensive spinal stabilization exercise program using elastic resistance tubing. She was shown how to incorporate an exercise log with her food diary, which she brought to each visit so her continued adherence to diet and exercise recommendations could be encouraged.

Response to Care

The adjustments were well-tolerated, and orthotics made a noticeable improvement in her postural alignment at the feet and the lumbopelvic region. Her low back symptoms resolved and her foot numbness decreased significantly. At eight weeks of 12 adjustments and daily home exercises, including wearing her orthotics, she was released to a self-directed maintenance program. She was encouraged to continue her diet and exercise program.


The combination of obesity and type 2 diabetes (insulin insensitivity) is a growing problem. Once referred to as “adult onset,” this type of diabetes is now seen in adolescents. One result of altered glucose levels is peripheral neuropathy, which can present as bilateral “glove and/or stocking” paresthesiae. If numb feet are repeatedly traumatized, they develop sores and infections, with a real risk of amputation. Proper shoe fit and frequent foot self-examination are necessary in order to prevent further deterioration of foot health.

Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.


To Stabilize Lumbar Fixations

History and Presenting Symptoms

A 56 year-old female describes a history of numerous episodes of lower back pain and disability. She reports that she has previously had physical therapy and chiropractic care, and has been evaluated by an orthopedic surgeon. None of the prior treatments has provided any long-term relief, since her low back pain returns, in spite of treatments and exercises. She says that she has evidence of spinal degeneration on her X-rays, but an MRI ordered by the orthopedic surgeon found no disc herniation or spinal stenosis. On a 100mm Visual Analog Scale, she rates her low back pain at about 45mm, with an occasional 80mm.

http://www.theamericanchiropractor.com/images/danchickartpic.jpgExam Findings

Vitals. The patient is a petite woman, who stands just over 5’ and weighs 122 lbs, resulting in a BMI of 23–she is not overweight. She has never smoked, and her blood pressure is 116/78 mmHg with a pulse rate of 68 bpm. She drinks wine and beer occasionally, and exercises regularly by walking briskly each morning with a neighborhood friend.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter. The right shoulder is somewhat lower than the left, with no history of fracture or surgery. Her knees are well-aligned and there is no significant calcaneal eversion, foot flare, or low medial arch. Inspection of her shoes finds some scuffing and wearing at the lateral aspect of both heels.

Chiropractic evaluation. Motion palpation identifies several limitations in spinal motion at the right SI joint, the lumbosacral junction, L2/3, and at the cervicothoracic junction. Except for the right SI joint and the right piriformis and gluteus medius muscles, palpation elicits no significant tenderness, and all active spinal ranges of motion are full and pain-free. Her hip ranges of motion are also full and pain-free bilaterally.


AP and lateral lumbopelvic X-rays in the upright, standing position are taken with the patient weight-bearing, heels aligned directly under the femur heads, and both knees extended. A substantial discrepancy in femur head heights is noted, with a measured difference of 8mm (left low femur head). A moderate left convex lumbar curvature (9°) is noted, and both the sacral base and the iliac crest are lower on the left side. There is noticeable loss of the L5/S1and L4/5 discs, with moderate osteophyte formation involving both motion segments. The sacral base angle and measured lumbar lordosis are within normal limits.

Clinical Impression

Multiple chronic lumbopelvic fixations, with an apparent anatomical leg length discrepancy (left short leg) and associated pelvic tilt and lumbar curvature. Evidence of chronic biomechanical stress is seen in the degenerative changes of the lowest spinal motion segments.

Treatment Plan

Adjustments. Specific chiropractic adjustments for the lumbosacral and sacroiliac joints were provided. Side-posture techniques were well tolerated in the lumbopelvic region, and resulted in very good articular releases.

Support. She was fitted with shock-absorbing, flexible custom-made orthotics based on imaging the foot in mid-stance (weightbearing). On a trial basis, she was temporarily fitted with a 4mm heel lift. A 6mm heel lift was permanently built onto the left orthotic. The stabilizing supports were introduced immediately, following the first week of regular adjustments. She had no difficulty in adapting to the heel lift or the orthotics.

Rehabilitation. She was instructed in a daily, at-home core strengthening program using elastic exercise tubing. The focus was on activation of her transverse abdominis and quadratus lumborum muscles, for improved spinal-pelvic stability.

Response to Care

This patient responded well to her spinal adjustments, and adapted well to her custom-made orthotics with the heel lift. After six weeks of adjustments (eight visits) and daily home exercises, she was released to a self-directed maintenance program.


This patient had chronic lumbopelvic fixations, caused by her anatomical discrepancy in leg length, that had not been previously identified. In addition to spinal adjustments, her treatment included correction of her left short leg using a heel lift.


Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.

Groin Strains

History and Presenting Symptoms

A 45-year-old male presents with occasional, moderate pain in his left hip and groin. He has been evaluated for hernia and arthritis, with no definitive diagnosis and no successful treatment. Physical therapy with various modalities and exercises felt good, but didn’t resolve his problem. He says that he has noticed these symptoms for at least the past six years, and possibly longer. He recalls no injury to his hip or groin, and reports that he has never been active in sports. On a 100mm Visual Analog Scale, he rates his left groin pain as about 40mm. He has not identified any specific activities that consistently worsen or improve the symptoms.


Exam Findings

Vitals. This middle-aged male weighs 187 lbs, which at 5’11’’ results in a BMI of 27–he is slightly overweight, but has not established a regular exercise program because of his concern about his groin pain. He tries to eat a low-fat diet, but travels for business and is frequently unable to eat healthily. He was a pack-a-day cigarette smoker, but quit successfully four years ago. His blood pressure is 124/84 mmHg and his pulse rate is 80 bpm.

Posture and gait. Standing postural evaluation finds a lower iliac crest on the left, and a low left greater trochanter. The right shoulder is somewhat lower than the left, with no history of fracture or surgery. His knees are well-aligned, but there is medial bowing of the left Achilles tendon, associated with calcaneal eversion. Dynamic examination of walking revealed excessive pronation of the left foot.

Chiropractic evaluation. Motion palpation identifies several mild limitations in spinal motion: the left SI joint, the lumbosacral junction, T11/12, and the cervicothoracic junction. There is no localized tenderness in these regions, and all spinal and hip ranges of motion are full and pain-free. Provocative regional orthopedic and neurological tests are negative.

Lower extremities. Closer examination finds that the left medial arch of the foot is lower than the right when standing. When he is seated and non-weightbearing, the left arch appears equal to the right, and when he performs a toe-raise while standing, the left arch returns. Manual testing finds no significant muscle weakness in the hip abductor or adductor muscles, although the right adductor muscles are “sore” when stressed isometrically.


AP and lateral lumbopelvic X-rays in the upright, standing position are taken while weightbearing. An obvious pelvic tilt and leg length discrepancy are noted, with the left femur head 7 mm lower. A moderate lumbar curvature (4°) is noted, convex to the left side, and both the sacral base and the iliac crest are lower on the left. The sacral base angle and measured lumbar lordosis are increased, but within normal limits. No loss of joint spacing or osteophyte formation is seen in the hip joints.

Clinical Impression

Moderate functional leg length discrepancy (left short leg) when standing, with associated pelvic tilt and slight lumbar curvature.

Treatment Plan

Adjustments. Specific, corrective adjustments for the SI joints and the lumbar, thoracic, and cervical regions, as well as soft tissue manipulation, were provided as needed. Manipulation of the left navicular, cuboid, and calcaneal bones was also performed.

Support. Flexible, custom-made stabilizing orthotics were supplied, with a pronation correction added to the left side. He had no difficulty in adapting to the orthotics.

Rehabilitation. He was shown a series of upright strengthening exercises for all hip ranges of motion, in order to speed the process of adaptation to the new alignment. After two weeks, he began a daily brisk walking program, progressing from 20 minutes to 40 minutes.

Response to Care

The spinal, pelvic, and foot adjustments were well tolerated, and the orthotics made a noticeable improvement in his postural alignment, at the feet and in the lumbopelvic region. After four weeks of adjustments (seven visits) and daily home exercises, including walking with orthotic support, he was released to a self-directed maintenance program.


Chronic biomechanical stress can cause low-grade nociception that is difficult to track down. Had this patient been more athletically involved, it is likely that his lower extremity asymmetry would have become more obviously symptomatic. With chiropractic care and foot stabilization, he could safely initiate a walking and exercise program for health and weight control.


Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.

Runner for the Cure Develops Heel Pain

History and Presenting Symptoms

A 25-year-old female presents with pain around her right ankle and heel. The pain has been present for about three weeks and gets worse upon weightbearing activity. She also relates running about six times per week for five miles a day, in preparation for her first half-marathon run in support of breast cancer awareness. She denies any specific injuries or direct trauma. Her medical doctor has diagnosed plantar fascitis, but she is not responding to the non-steroidal anti-inflammatory medications he prescribed.

Exam Findings

Vitals. This active young woman weighs 127 lbs. which, at 5’5’’, results in a BMI of 22; she is not overweight. She does not use tobacco products, and her blood pressure and pulse rate are within the normal range. Posture and gait. Standing postural evaluation reveals basically good alignment, but a decreased lumbar lordosis. She demonstrates bilateral calcaneal eversion, worse on the right, with a lower right arch. Gait evaluation finds obvious hyperpronation of the right foot and ankle when walking, which is accentuated when running. Chiropractic evaluation. The lumbar spine is moderately tender throughout, and she demonstrates a generalized loss of vertebral mobility, with few specific fixations. Orthopedic and neurological provocative testing of the spine and pelvis is negative. Primary complaint. Palpatory examination of the right foot elicits significant tenderness to medial/lateral squeezing of the right calcaneus. No point tenderness is noted at the insertion of the plantar fascia into the anterior aspect of the calcaneus. All right foot and ankle ranges of motion are full and pain free. Also, manual muscle testing reveals no evidence of weakness when compared to her left side.



A lateral X-ray of the right foot demonstrates a calcaneus and talus that appear normal. There is no evidence of fracture, sclerosis or periosteal reaction.


Clinical Impression

Stress response in the right calcaneus bone, with moderate lumbar spine joint dysfunction. There is no evidence of plantar fascitis or subtalar joint malfunction.

Treatment Plan

Adjustments. Mobilization and adjustments were provided to the lumbopelvic region. The right calcaneus was adjusted anteriorly and both navicular bones were adjusted superiorly. Support. Flexible, stabilizing orthotics with shock-absorbing viscoelastic materials were custom made to support all three arches of each foot, in order to decrease calcaneal eversion and heel-strike shock. Rehabilitation. A foot-wheel device was recommended to improve the coordination of her foot intrinsic muscles. Once she had her orthotics, she also performed standing Achilles tendon stretches with knee straight, and then bent.


Response to Care

She was told to avoid walking as much as possible for the first week, and then only limited walking for two more weeks. She was permitted to increase her walking over the following three weeks and gradually incorporated short periods of running. At six weeks, she returned to her training program with no recurrence of heel pain, and she was released to a self-directed home stretching program after a total of 10 visits over two months.


Stress fractures generally occur in the lower extremities, beginning as a stress response that can progress to a frank fracture. It is often said that a stress fracture is a normal response of bone to abnormal doses of stress. The rear foot or heel area of athletes is particularly susceptible to these overuse injuries, as most sports and training activities include a component of running, which places large amounts of stress on the anatomical structures of the foot and ankle. There is a higher incidence of stress fractures in young women (10:1), which is thought to be associated with their smaller bone structure, decreased lean body mass, and possible poor nutrition secondary to eating disorders.

Initial radiographs may be negative in up to 70% of patients with stress fractures. The radiographic evidence of stress fractures often lags two to three weeks behind the onset of symptoms. Typically, there will be a dense margin of sclerosis perpendicular to the trabecular meshwork and parallel to the posterior contour. Serial radiographs or radionuclide bone scans may be necessary when the initial diagnosis is questionable. In this case, the exam findings and response to treatment were clear, and no further imaging was needed.


Dr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.

Audit Proof Your Practice

The curse is that insurance companies use computers to burden and audit you. The blessing is greater because the computer protects you from audits, minimizes paperwork and eliminates 95% of paper filing.


Doctors praise Electronic Health Record (EHR) computers. When audited, those doctors produced high quality SOAP records that matched the bills. The only loss was a small amount of time to deal with the audit.

On the other hand, there are horror stories from colleagues that did not have good notes. The auditors came, found the documentation did not match the billing, and demanded refunds from a few thousand to more than half a million dollars. Then the auditors filed complaints with state boards and departments of fraud. If notes do not match billing, an audit will turn your life into hell.


You have the ability to audit proof your office. It begins with fully integrated EHR management and a documentation computer that guarantees notes and billings match. The patient is signed in, the patient’s name automatically appears in the adjusting room, enters the SOAP note including the services performed, the taps and clicks are converted into a dictation quality note, and the documentation generates the charges. The patient signs out electronically, verifying the services and accepting responsibility to pay. In the event of an audit, there is a perfect match between the notes and billing, and electronic proof that the patient received the services.


Take a realistic look at your practice. Do your notes and bills match? If your answer is, “NO,” then you are open to a devastating audit. For your own benefit, fix this dangerous situation before the auditor comes. Use an EHR system and bill only for documented services.  


Are there times you perform a service, bill for it, but do NOT document it? An insurance auditor will use this to prove fraud, and there is nothing you can do after the fact to prove the falseness of the accusation. When using an EHR program where documentation produces the billing, there is never a bill that is not documented.


How frequently does a patient tell you something that you do not include in your records? What recommendations to patients are not in writing? Computerized SOAP documentation makes it simple, fast and easy to include these things. Using a tablet computer with handwriting recognition, it is a breeze to just jot something into the progress note and have it appear as if it was typed. Some programs integrate with Dragon Naturally Speaking, allowing you to dictate, converting your speech into typed text. The critical point is to record everything that the patient tells you, as well as to record all the advice and recommendations you gave.


A cash, pay as you go, practice does NOT protect you from audits. Although it reduces the chances of being audited, there are many cash practices that have been audited. The courts ruled that, as soon as a patient submits a receipt for services to insurance, you are held to the same standard as if you were a participating doctor accepting assignment. This means that, even in a practice where every patient pays you up front and you never send anything directly to an insurance company, the insurance company has the right to audit. Some cash practice doctors have had an extremely rude awakening, being required to refund substantial amounts, and then having to deal with departments of insurance fraud. The bottom line is that, no matter what type of practice you have, it is critical that your billing and documentation match.


Documentation extends beyond SOAP notes. Do you send letters to patients? Better EHR office management and documentation systems include templates for letters and documents, and save a copy of each in the patient’s file. Narrative reports are saved as part of the electronic record.

There should be a record of every phone call, including the date and time of the call, who was spoken to and what was said. EHR systems include phone logs in each patient file, and this phone log may save you a lot of grief. A real life example: Several years ago a mechanic came in with severe low back and leg pain. The doctor determined the patient had a disc lesion, and treated it. The patient felt relief and went home with instructions for bed rest and to return the next day. The patient did not return. The doctor called to find out what happened. The patient’s wife answered and reported that the patient felt so much better that he was outside, under his truck, replacing the transmission. The doctor entered this in the patient’s phone log. A few weeks later, the doctor received a records request from an attorney. The records with the log were sent to the attorney, and that was the end of it. The doctor learned that the patient ruptured his L5 disc while changing the transmission, but was blaming the doctor. If the log had not been maintained, the doctor would have had a nasty malpractice suit.


Even in a practice where every patient pays you up front and you never send anything directly to an insurance company, the insurance company has the right to audit.

Police reports, MRI or other reports, pictures, explanation of benefits (EOB’s) and other documents need to be part of the patient’s records. EHR programs include the ability to scan these things into the patient’s file, making them accessible at the touch of a button.


In an audit, it is necessary to prove that you are always aware of clinically special items about a patient. This could be a message regarding a condition (osteoporosis, gibbus formation, disc herniation, spina bifida) or to use a specific procedure. EHR programs include these notices as pop ups in the patient’s file, and the record of these pop ups can be printed easily.

Dr.-Paul-BindellThe blessing of the right EHR computer system is that it protects you from audits, saves you time in the office, and increases your income. The time to accept and use this blessing is before an auditor pays you a visit.


How to Get Paid with Insurance

You treat Mrs. Jones today, complete your fee slip, and your insurance staff has every document necessary to bill the claim. They have the application for benefits and/or proper claim forms from the patient, along with the correct policy numbers. The staff also has all of the completed notes/letters of necessity/results required ready as attachments to send with the claims, and you send the claim to the carrier within 48 hours of service. The insurance carrier either pays your bill in full or lets you know why they are not paying within a 30-45 day window, and you have no receivables beyond 45 days. Your accounts receivable for insurance are $0.

Have you accused me of being delusional yet?


Here’s the typical office:

You see the patient, fill out a fee slip and you give it to your front desk. They, in turn, give it to the billing staff that enters the codes into the computer. In many cases, the staff chooses the diagnosis from a list you have given them without their having a shred of education on how to accurately cross link codes. The Health Care Financing Administration (HCFA) form, or some similar form, is created and then sent to the insurance company, usually with no attachments, and you are hoping for prompt payment.

Every 30 days or so, your billing staff prints out a computer log of accounts receivable and starts to call on the delinquent ones. Historically, the staff chooses to wait 45-60 days until they start to call to collect on the claims. During this time, they let the insurance correspondences back up, even though most issues have a 30-60 day time frame in which to respond before your rights to get paid expire. Most offices do not respond in a timely fashion and that is exactly what the carriers count on.

 Here are the issues:

1. You have a billing staff and most have no experience or education in collections. Usually they have no training in billing and neither do you. Collectors have to know the laws of the state that the insurance companies have to abide by.

 2. Computer receivable logs do not work. Most of the staff gets through A-M in the alphabet each month, if they are lucky. The N-Z list rarely gets the attention that A-M does. Ask your staff.

3. Picking up the phone as your primary collection tool is a failed technology. If you have 20 claims generated per day, a good collector can only get 4-5 claims resolved in a day. If you take into account being put on hold, not being able to locate the file and the callbacks required, 4-5 on the average is good. That means, if you get paid on 50% of your claims without calling and you have not gotten paid on 10 claims per day, each day in practice, you fall behind 5 claims. It’s not your staff’s fault; it’s your system that doesn’t work. It will soon be your staff that doesn’t work also, because they will quit out of frustration of working in a system that is set up for failure. Verify the facts, not with your staff, but by looking for yourself…. It’s your money.

4. When you pick up the phone, you are begging and pleading with the insurance companies to get paid, and you will fail more than you will succeed. The moment you pick up the phone, you are playing the insurer’s game and they know it. This is where the laws of your state need to be utilized as leverage to get paid for services rendered.

5. You will end up treating a good portion of your patients for free. Those letters that the insurance company sends you are designed to “paper you to death.” They know that you cannot handle the paper burden, and they have also profiled who does not respond to them in a timely manner. Read the back of the explanation of benefits. Most states require the carriers to print the statutes on the claim directly. Some states simply require that you know.

I was in a similar situation, and I was tired of treating patients for free. Well, not really for free. I had to pay for my staff, the supplies, the electricity, the insurance, the rent, the ink to write the notes, and I was liable for every patient I touched, so it wasn’t for free. I had to pay a lot of money to treat those patients.

First, you and your staff need to know the laws in your state. Start by calling your state’s Department of Insurance and asking them the mandated time frames for insurance companies to either pay or report to you that there is a legal delay in the claim. In New York, for instance, the carriers have 30 days to pay your personal injury claims (NYCRR 65.15(e)(2)) and, if they do not pay or notify you of a “legal” delay, they have to pay you 2% per month without the assignee (doctor) demanding interest payment (65.15 (e)(2)(h)). Most other states have similar laws.

If a carrier did not pay me within the mandated time frame, my office sent them a notice that, if they did not pay our claim, we would report them to the New York State Insurance Department and Consumer Service Bureau, and they would be fined $500 per day, per HCFA, as penalty by the State of New York under the “Prompt Pay Law” (Section 3224a of the New York State Insurance Law). We had a form letter that stated the law and it was sent to the carrier via mail with a copy of the HCFA form.

Again, most states have similar laws.

If there were 50 unpaid and unanswered claims each day, how long did it take a staff member to pull the claim, copy it, attach a delinquent letter and put it in an envelope? Each staff member could complete over 50 collection actions per day and we never fell behind, no matter the volume. This is versus the 4-5 you can get on the phone to complete a collection action. Occasionally, we did pick up the phone on larger claims, but our story was the same when we eventually got the carrier on the phone.

Your current conversation is, “I sent you the claim. Pay my bill…pleeeeeeeeeeease!!!!! Look at your statistics and see how well you are doing with that plan.

By using the laws of my state, we went from 50% collections to 90% of the fee schedules. The balance we either litigated and/or arbitrated and I have successfully gone through this process in multiple states.

You cannot beg and plead for your money. There are laws in every state to protect you and, those that understand the laws and use them get paid. The insurance companies profile you and know who begs and pleads versus those who utilize the law to rightfully get paid. The latter group gets paid with much greater ease.

You are entitled to get paid a fair fee for every service that you render.

Dr.-Mark-StudinDr. Mark Studin is the President of C.M.C.S. Management which offers the Lawyers Marketing Program,Family/MD Marketing Program and Compliance Auditing services. He can be contacted at www.TeachChiros.com or call 1-631-786-4253.

Low Back Pain Leads to Lifestyle Changes

History and Presenting Symptoms

A 41-year-old male presents with a history of recurring episodes of mild to moderate pain in his lower back. He states that his back pain just seems to come and go, with no specific triggering activities. He does not participate in any competitive or recreational sports, and recalls no injury or trauma to his back. He has recently been diagnosed as a borderline non-insulin dependent diabetic, and is trying to improve his diet to manage his blood sugar levels.

 Exam Findings

Vitals. This heavy-set man in his early forties weighs 218 lbs, which at 5’10’’ results in a BMI of 32—he is not just overweight; he is obese. Since he reports no regular exercise, his additional weight is very likely due to excess fat mass. Although he is a non-smoker, his blood pressure and pulse rate are both elevated—144/96 mmHg and 88 bpm. His waist circumference measures 48 inches, indicating that he is carrying much of his weight around his mid-section.

Posture and gait. Standing postural evaluation finds generally good alignment throughout his pelvis and spine, but a flattened lumbar lordosis with a large abdominal load. He has bilateral knee valgus and calcaneal eversion, with pes planus and hyperpronation bilaterally. During gait, both feet demonstrate an obvious toe-out. Inspection of his shoes finds scuffing and wearing at the lateral aspect of both heels.

Chiropractic evaluation. Motion palpation identifies limitations in segmental motion at L4/L5 and L5/S1, with local tenderness. Both of these segmental dysfunctions demonstrate loss of endrange mobility in all directions. Additional fixations are noted at T12/L1, T9/T10, C5/6, and C1/2. Lumbar ranges of motion are somewhat limited in all directions by his excess weight, and extension is limited to 10° by localized back pain. Neurologic testing is negative, although his deep tendon reflexes are generally sluggish. Examination of the knees and ankles finds no ligament instability, and all knee and ankle ranges of motion are full and pain-free.



Upright, weight-bearing X-rays of the lumbar spine demonstrate loss of intervertebral disc height at L4/L5 and L5/S1, with moderate osteophyte formation at those levels. There is no discrepancy in femur head or iliac crest heights, and no lateral listing or lateral curvature is noted.


Clinical Impression

Moderate lumbosacral osteoarthrosis and disc degeneration, with mechanical dysfunction. There is also poor biomechanical support from the lower extremities, and his condition is exacerbated by the excess weight his skeletal structures must carry.

Treatment Plan

Adjustments. Specific chiropractic adjustments for the lumbosacral, lower thoracic, and cervical spinal regions were provided as needed.

Support. Custom-made, flexible stabilizing orthotics were provided to support the arches and decrease stress on the knees and back.

Rehabilitation. This patient was shown elastic tubing exercises to begin strengthening his spinal stabilizers and core musculature. He was also instructed to gradually initiate a daily brisk walking program to increase his metabolic rate.

Response to Care

He responded well to his spinal adjustments, and to the reasonable changes in diet that were suggested. He also adapted quickly to his orthotics, which allowed him to begin his program of brisk walking without exacerbation of back or leg pain. He was very dedicated to his home spinal stabilization program, and enjoyed showing the progress in his exercise log. After six weeks of adjustments (10 visits) and daily home exercises, he was symptom-free and had lost 17 pounds. At that point, he was released to a wellness program to oversee his continued exercise and weight loss program.


This patient was obese, based on his BMI, and he had three of the signs of Metabolic Syndrome—waist circumference over 40″, blood pressure over 130/85 mmHg, and elevated blood glucose (by report). In addition to experiencing chronic stress on his musculoskeletal system, he was also at risk of developing diabetes, cardiovascular disease, and an early death. His chiropractic care included orthotics to support his strained lower extremities, and specific exercises to improve his core stability, along with dietary recommendations. As is true with most patients, he was aware of the necessary lifestyle changes for health, but needed guidance and professional support through the initial stages.

Dr.-John-J.-DanchikDr. John J. Danchik, the seventh inductee to the ACA Sports Hall of Fame, is a clinical professor at Tufts University Medical School and formerly chaired the U.S. Olympic Committee’s Chiropractic Selection Program. Dr. Danchik lectures on current trends in sports chiropractic and rehabilitation.

CALL FOR ACTION: An Open Letter to the Chiropractic Profession

Dear Chiropractic Colleague:

This profession-wide “Open Letter” has been issued for a most urgent reason.

Ignore it at your own peril

Comprehensive and far-reaching “National Health Reform” legislation is rapidly moving forward in Congress. It is abundantly clear, that the legislation under consideration could substantially alter America’s health delivery system in dramatic and perhaps unexpected ways.

Depending on the detailed legislative provisions that are ultimately passed into law – the final legislation could either greatly benefit or harm the chiropractic profession and the patients we serve.

Make no mistake about it: Every doctor of chiropractic – regardless of your business model, patient mix or practice location will be greatly affected.

A major controversial issue concerns the proposed establishment of a new “Public” health plan that would be made available to consumers in all 50 states.

Virtually all observers agree this new plan would, as a practical matter, establish a new, national “standard” with respect to health care benefits and services deemed to be “essential” and worthy of inclusion in health insurance plans.

In addition to the new “public” health plan, it is highly likely that Congress may also establish coverage and benefit standards for all private insurance plans that will be marketed through a newly created network of “exchanges” – the dominant mechanism through which consumers are expected to chose their preferred health insurance plan, once a comprehensive reform plan has been enacted into law.

Obviously, if Congress were to decide, as part of the reform process, that chiropractic benefits and services are “essential” – and, thus, important enough to be included in the minimum benefits packages of the new “public” plan (along with those private plans that will be required to match the same standards as the national public plan), then millions of consumers will, for the first time, gain guaranteed coverage of chiropractic services. Likewise, if chiropractic care is not included as a guaranteed covered benefit, then millions of consumers will be channeled into health plans that offer no coverage of chiropractic care. Some patients could even lose their existing coverage for chiropractic care.

In short, our profession has much to gain and much to lose, depending on the precise legislative provisions that are ultimately agreed to by Congress and President Obama.

As you may know, the unified Chiropractic Summit, a joint, cooperative effort of over 40 chiropractic organizations including the American Chiropractic Association (ACA), the Association of Chiropractic Colleges (ACC), the Congress of Chiropractic State Associations (COCSA), and the International Chiropractors Association (ICA),– is aimed at achieving common goals and objectives relative to the national reform issue.

This historic joint effort is helping in very significant ways to raise the profile of the chiropractic profession on Capitol Hill and to send a unified, persuasive message to Congress that has already gained important support for prochiropractic provisions of law.


Sadly – and with great risk to the future of the chiropractic profession – too many DC`s (and their patients) continue to sit on the sidelines and have not yet engaged in the critical grassroots lobbying efforts that are so urgently needed to ensure victory.

The purpose of the “Open Letter” is to make it crystal clear that it is ABSOLUTELY IMPERATIVE that every DC in the nation take IMMEDIATE ACTION to contact and lobby Congress.

Use AdjustTheVote.org and ChiroVoice.org to mobilize our strongest asset in this struggle, our patients!

The time for action is NOW…!!! Do not fail to do your part to ensure the protection of both your profession and future. REMEMBER: Your enthusiastic response to this URGENT APPEAL FOR ACTION can make the difference between victory and defeat. TAKE ACTION NOW – as time is running out…!!!




Glenn D´. Manceaux, DC, President, ACA; Frank Nicchi, DC, President, ACC; Jeff Fedorko, DC, President, COCSA; Gary Walsemann, DC, President, ICA.

Chiropractic: A Profession in Dire Need of Unification

In 1989, as an 8 year practitioner, I was angry at the state of politics in New York. Not being one to be idle, I was determined to right the ship, so a group of five professionals got together and had a decision to make. Should we infiltrate the current state organization and “right the ship,” or should we create another organization, as the existing one was too flawed and would waste too much time and energy to correct?

Our arguments were compelling; there was verified corruption, a political machine that best served those in power and their friends and, worse, our reputation with state legislators was an embarrassment, as it was negatively affecting our political agenda. As a result, we five created an organization that is still quite vibrant and active in New York chiropractic politics.

I was a key figure in that organization and its activities for almost ten years, having served almost every position and having raised approximately $500,000 for the organization in a five year period. I was active in our state legislature; forging many relationships that served our profession well…. You get the picture.

 “The biggest problem I have in supporting chiropractic is you can’t even get together within your own profession. Therefore, I get conflicting information that makes me lean towards the opposition.”

During that same ten year period, the biggest problem I had was neutralizing the competitor’s organization, so it would not stand in the way of our legislative agenda. The result (the truth), I am a self-proclaimed political failure, as I raised the money, made the right political connections, hosted the right party’s fund raisers for candidates, got invited to the right events, was placed on the right committees and was recognized for being instrumental in helping candidates reach their goals. I was a hit for many years in New York politics!

Where did it get chiropractic in New York State? Nowhere! It has been twenty years since I first made that decision to “right the ship” and chiropractors in New York State have gotten virtually nowhere in those twenty years, with multiple organizations contributing to that failure, and I am personally accountable for that.

Last month, when the national debate was heating up on national health care reform, I searched both the ACA and ICA web sites for a way to communicate with my national legislators supporting chiropractic. As I am a member of both national organizations, I went to both web sites. The ACA’s www.chirovoice.com and the ICA’s www.adjustthevote.com are both great vehicles to support chiropractic. Both organizations have a program, and which one is more effective is not relevant to this conversation. The point is that both organizations paid to have the exact same service for the chiropractic profession.

The national organizations, just like the state organizations, have a political agenda to further chiropractic. How many senators, congressman and legislators get one meeting from each organization? Even if both organizations want the same thing, my experience is that there are two different messages delivered and that is confusing to a legislator who is hearing a third message from the opposition and sometimes multiple opposition messages.

The answer given to me by a New York State Senator still resounds in my head years later: “The biggest problem I have in supporting chiropractic is you can’t even get together within your own profession. Therefore, I get conflicting information that makes me lean towards the opposition.”

He was right then, and still is today, because we have continued to send multiple messages nationally, and locally.

To help resolve this issue, the Chiropractic Summit was created to help give a unified voice legislatively on Medicare reform and national health care reform. The Chiropractic Summit now has forty different organizations with both national and local organizations participating. According to Dr. Lewis Bazakos, Chairman of the Chiropractic Summit, “It is a giant step towards unifying our message and critical to the success of the chiropractic legislative agenda, but it’s still not enough.”

Dr. Bazakos is right and the nation should listen to him very carefully. Whether or not you like his politics, we owe a great debt of gratitude to doctors like him who have given back to the profession for their entire career through public service and we should go one step further. We should listen to him. His words scream for reform in order for chiropractic to succeed for generations to come.

This Chiropractic Summit is yet another forum of critical necessity because we are split as a profession. How much time and money is wasted because we have two national organizations?

The United States currently has a two party system to debate the issues and there are mechanisms of checks and balances in our Constitution that have served this country well since 1776 with one president. Not so for the chiropractic profession; we have two federal organizations that have no checks and balances. Each has its own president, constitution and agenda that has two directions, two messages and two sets of beaurocracies to fund. We have two of everything that this profession can ill afford to waste its resources on.

Look at the profit and loss statements of both national organizations. How much money is spent on duplicitous rent, secretaries, web sites, journals, newsletters, mailings, mail-in votes, etc.? How much longer can we keep squandering our resources while chiropractic is stuck in the mud politically and where a chiropractor isn’t considered worthy enough to take or order any imaging through Medicare?

I teach MRI interpretation and am certified by my state’s education department, in addition to being approved to render AMA Credits on teaching spine MRI interpretation through a medical school, yet I am not even allowed by the Medicare program to order an MRI, whereas dentists, who have no training, can order any imaging they want in the federal programs. Disgusting!

Every state only needs one organization. I have lived through that grievous error and, nationally, we, too, need only one organization. Within each organization there can be committees that serve the needs of every chiropractor in every state. Principled, straight, mixers, subluxation-based, structural based, wellness or pain-based practitioners; it’s all a bunch of nonsense.

Open your eyes and realize that a chiropractic organization is a political organization and nothing more. It exists to further the chiropractic profession and ensure that every chiropractor in your state or the country has the ability and right to care for every citizen of the United States. Its real purpose is nothing more than that. Under the umbrella of that organization is where individual agendas should exist regarding furthering issues such as extremity adjusting, nutrition, pediatric care, etc. It doesn’t matter the issue. In the end, supporting a separate organization will erode chiropractic. Ask me; I have lived through it.

In retrospect, back in 1989, in spite of the corruption, the cronyism, and the political machine that was not serving all of us, I should have worked tirelessly to get that organization “righted” instead of splintering the profession in my state. The result would have served chiropractic and our patients better. The following is a direct message to those who serve our national organizations: We support, applaud and appreciate your public service and owe each of you a large debt of gratitude. I, personally, know the sacrifices you have made with your family, practice, time and money to help me and the rest of the profession to ensure our rights to practice as we choose. However, in spite of the glorious history of both the ACA and the ICA, it is past time that we have one organization, one voice and a lot more money to further our profession. It is time to create one organization and merge.

Dr.-Mark-StudinDr. Mark Studin is the President of CMCS
Management which offers the Lawyers Marketing Program,Family/MD Marketing Program and Compliance Auditing services. He can be contacted at www.TeachChiros.com or call 1-631-786-4253

Marketing Using Your EHR Computer System


Everyone knows that Electronic Health Record (EHR) systems are mandated under an assortment of Federal laws and Presidential edicts. Other than maintaining patient SOAP documentation and billing records, the better EHR programs include many marketing tools to build your practice and increase your income.

How much income did your computer create for you? Is your computer program capable of doing more than just one function, or is it limited to only billing or only documentation? In today’s world, it is critical for you to have and use a complete EHR computer program that is a multi-tasking, income generating machine.


Included in the marketing tools built into the computer software are letters, email capabilities, follow up reminders for staff and other functions and features that empower you and your staff to efficiently bring in new patients and referrals from attorneys, employers, diagnostic centers, and other doctors. Many of these same tools can be used to promote your practice to your existing and former patients, maintaining a high level of patient compliance with your recommendations.

Marketing the practice to attorneys, employers and other doctors requires that you build a list of each of these categories. Top of the line EHR software may label it differently, so look for lists, catalogues, directories, or registries for each category. Then enter the information in the system. Start with those attorneys, employers and doctors that are already connected to your patients. Next, have a staff member pull more names and addresses from your local phone book.

Once the lists are ready, depending on the software, you may have marketing letters already in your system, you may need to create your own templates, or you may want to revise and add to the letters from the software company. The marketing letters will have insertion fields that pull information directly from the lists, so that each letter is personalized to each attorney, employer or doctor. The final step is to print all the letters to each group and mail them. Doing this on a monthly basis gets the result of more referrals to your practice.

Patients love to be recognized and made to feel special. Sending personalized letters with regularity accomplishes this. Direct patient marketing educates patients as to why each needs to be consistent and follow through with the care you prescribe. Similar to the marketing to attorneys, employers and doctors described above, letter templates are in the EHR program that are specific for patients. These letters educate the patient about chiropractic care and encourage him/her about the benefits of not only therapeutic care but also the value of maintaining treatment after the symptoms are gone. Since each letter is personalized, the direct patient marketing builds rapport and trust with the patient. Letters in template format are easily merged with the patient list using search and sort criteria that you select. The bottom line is that your patient visit average (PVA) goes up, and so does your income and the referrals you get from patients.

Complete EHR systems that generate SOAP notes in dictation quality English and/or produce excellent narrative reports market your practice by building relationships with attorneys and other doctors.

With your patient’s written authorization, send a copy of your SOAP notes or narrative report to the patient’s other doctors. As long as it is easy to read, looks like it came from a professional, and lets the other doctor know what is going on, you will gain the respect of that doctor. As you demonstrate that you are part of the team working to get and keep the patient healthy, the other doctors will realize that they can work with you. Eventually, many will send referrals.

In a similar way, if you produce detailed easy to read narratives, attorneys will appreciate your work. The reason is simple. You are giving them the meat and potatoes that will win the case for the patient, meaning that the attorney makes more money. When you contribute to the attorney’s success, the attorney will frequently help to make you more successful.

Frequently, little things make a big difference. A mini-marketing tool in EHR programs is the ability to place messages on each billing statement or receipt that you send/give to a patient. These little messages can improve collections, increase patient visits, or engage each patient to be politically pro-active for laws that will benefit chiropractic in your state.

Although it is not commonly considered marketing, having an easy mechanism to follow up on missed appointments is recall and reactivation marketing.

Although it is not commonly considered marketing, having an easy mechanism to follow up on missed appointments is recall and reactivation marketing. Thorough EHR software includes missed appointment tracking in an appointment scheduler as part of the system. If a patient misses an appointment, then that patient’s name remains on a missing patient list until the staff either reschedules the patient or purposely removes him/her for some other reason. The staff can set reminder pop up messages for specific times or days on which to call the patient. Another aspect of recall and reactivation marketing is a report for patients without appointments. If a patient canceled without rescheduling and never called again, you have the ability to track down and get that patient back in the office for the needed care. Your staff now has the tools to track down every patient that previously “slipped through the cracks” and not to let go until the patient has been rescheduled. Once again, proper marketing increases your PVA and collections.

Marketing on a consistent basis is the key to success. In order to make your practice the most successful, be sure to use every marketing tool at your disposal. EHR systems provide many marketing tools; be sure that your office software includes and that you are getting the maximum benefit from the marketing tools built into your practice management computer program. 

Dr.-Paul-BindellDr. Paul Bindell is a 1975 graduate of Palmer College of Chiropractic, in active practice in Rockaway, NJ, since 1976. He has lectured on chiropractic in Brazil and Israel. Dr. Bindell is a past Chairman of Public Relations for the Northern (NJ) Counties Chiropractic Society. Dr. Bindell and his family began Life Systems Software so that the profession would have reliable computer programs based on real chiropractic practice. Dr. Bindell and have appeared in several chiropractic journals. Dr. Bindell is available to speak to your group or organization and can be reached by email at [email protected], or you can call Life Systems Software at 1-800-543-3001